On July 21, 1999, a 54-year-old machine operator
at a paper manufacturing plant was found dead in a paper pulp storage tank.
No one saw the incident. The victim was discovered missing from his workstation
near the chest and was found when the tank was drained to investigate a seized
belt. Apparently the victim fell into the tank through a small access hatch,
possibly as he stepped over the hatch to take a shortcut to his work area.
NJ FACE investigators concluded that, to prevent similar incidents in the future,
these safety guidelines should be followed:

Employers should conduct a job hazard analysis of all work activities with the participation of the workers.

On July 27, 1999, NJ FACE personnel were informed
by a county medical examiner of a machine-related fatality that occurred on
July 21, 1999. FACE investigators contacted the employer and conducted an investigation
on August 11, 1999. During the site visit, FACE investigators met with company
representatives before examining and photographing the incident site. Additional
information on the incident was obtained from the OSHA investigation file, police
report, and medical examiner's report.

The employer was a paperboard manufacturing plant
located in an urban area. In operation since 1903, this plant had been purchased
in 1984 and modernized by the current owner. Changes included cleaning up the
plant and investing in new equipment. The processes were also modified to use
100% recycled materials and discontinue adding chemicals to the paper. The
employer stated that these changes greatly improved production while decreasing
worker injuries. A safety program was also instituted that included safety
training and regular safety meetings. Ninety-six employees worked at the plant
in a three shift, 24 hour - 7 days per week operation. Employees were covered
by a labor union.

The victim was a 54-year-old male Beater Engineer
(beating machine operator) who had worked at the plant since May 1985. He started
as a Chemical Mixer, then worked as a Slitting Machine Operator in 1987 before
moving to his current position as Beater Engineer in 1989. His responsibilities
included operating a paper mixer (beater) and testing the paper pulp fibers.
He was born in Egypt, spoke English, and was married.

The victim had a significant medical history of
heart disease and diabetes that may have possibly contributed to this incident.
The employer stated that they accommodated his needs by moving him to the day
shift, but were not fully aware of the extent of his condition.

INVESTIGATION

Background

The paperboard manufacturing process starts with
the receipt of bales of recycled cardboard and paper at the plant. The bales
are immersed in an agitation tank of 165° F water, breaking the
paper down into fibers. The defibered paper or paper pulp is processed, separated
by color, and temporarily stored in an underfloor “chest” (storage tank) where
it circulates until needed. Pulp from the chest is pumped in a 4% solution to
a paper machine that evenly distributes the pulp onto a fabric belt. Additional
layers are added until the paper reaches the desired thickness, then it is run
through a series of heated drying rolls. Starching, cutting, and rolling finish
the paperboard process.

The victim's work area was near a paper pulp chest
that fed one of the paper machines. The hatchway to the chest is located between
two large machines. Employees sometimes used this as a shortcut, climbing over
some pipes and the hatchway to get by the machines. The hatchway measured 24
inches square and was raised 22 inches off the ground, with the chest underneath
about twelve feet deep. A heavy metal grate was fitted to the hatchway. Paper
pulp is pumped into the chest through a four-inch diameter pipe passing down
through the hatchway. Inside the tile-lined chest was a propeller agitator that
circulates the pulp. One of the victim's responsibilities was to watch the
chest and refill it when needed. Every 45 to 60 minutes he would throw a switch
located about 30 feet from the hatch that activated the pump feeding the four-inch
filler pipe. The pump was shut down when the chest was full, often when the
operator saw pulp overflow the hatchway onto the floor. The victim also assisted
with other processes around the plant.

There were no witnesses to the incident. The victim
was working the plant’s night shift that ran from 10:30 p.m. to 6:30 a.m. He
had worked overtime for the past couple of weeks, including 56 hours the week
prior to the incident. At about 11:40 p.m. he helped to fix a paper break in
one of the paperboard machines. Fixing a break was hot and heavy work because
of the heat from the rollers and the large size of the paper. The victim was
reportedly described as pale and not looking well when he returned to the paper
pulp chest, and was last seen by a foreman at 12:20 a.m. At about 1:40 a.m.
a supervisor contacted the plant manager at home to say that they could not
find the victim. The plant manager arrived at the plant to help search for
the victim when someone smelled burning rubber from a seized belt on the chest
agitator. Fearing that the victim had fallen in, they started to drain the
chest and found a rubber boot blocking the drain. The plant manager called
the police who were present as the remaining pulp was drained and the chest
was entered and searched. The victim was found entangled around the agitator
propeller and was pronounced dead at the scene. Fatal injuries included multiple
impact and thermal injuries.

It is not known how or why the victim was in the
chest. It is possible that the victim fell in as he walked over the open hatchway
while taking a shortcut between the machines. He may have also fallen in while
looking down or sitting on the edge of the hatchway. The victim’s medical condition
and long working hours may have fatigued the victim and contributed to this
incident.

RECOMMENDATIONS AND DISCUSSION

Recommendation #1: Employers should conduct
a job hazard analysis of all work activities with the participation of the workers.

Discussion: It is not known how the victim
fell into the paper pulp chest. However, several factors may have contributed
to the incident, such as the hatchway being located in an area that could be
used as a shortcut path. The surfaces in the area were also slippery from the
wet paper pulp. To prevent incidents such as this, we recommend that employers
conduct a job hazard analysis of all work areas and job tasks with the employees.
A job hazard analysis should begin by reviewing the work activities that the
employee is responsible for and the equipment needed. Each task is further
examined for fall, electrical, chemical, or any other hazard the worker may
encounter. The results of the analysis can be used to design or modify a written
safety program. If employers are unable to do a proper job hazard analysis,
they should hire a qualified safety consultant to do so.

Following this incident the employer installed
metal bars across all the chest hatches to prevent unauthorized or accidental
entry. The employer may want to consider installing railings near the machines
and hatch to prevent it from being used as a shortcut.

Discussion: FACE recommends that employers
emphasize worker safety by developing, implementing, and enforcing a comprehensive
safety program to eliminate or reduce hazardous situations. The safety program
should include, but not be limited to, the recognition and avoidance of fall
hazards and include appropriate worker training. The following sources of information
may be helpful in developing a safety program and obtaining information on safety
standards:

U.S. Department of Labor, OSHA

Federal OSHA will provide information on safety
and health standards on request. OSHA also has several offices in New Jersey
that cover the following areas:

The PEOSH act covers all NJ state, county, and
municipal employees. Two departments administer the act; the NJ Department
of Labor (NJDOL) which investigates safety hazards, and the NJ Department of
Health and Senior Services (NJDHSS) which investigates health hazards. Their
telephone numbers are:

Located in the NJ Department of Labor, this program
provides free advice to private businesses on improving safety and health in
the workplace and complying with OSHA standards. For information on how to
get a safety consultation, call (609) 292-0404, for a health consultation call
(609) 984-0785. Requests may also be faxed to (609) 292-4409.

New Jersey State Safety Council

The NJ Safety Council provides a variety of courses
on work-related safety. There is a charge for the seminars. Their address
and telephone number is: NJ State Safety Council, 6 Commerce Drive, Cranford,
NJ 07016, telephone (908) 272-7712

Internet Resources

Information and publications on safety and health
standards can be easily obtained over the internet. Some useful sites include: